General Assistance Application (Page 3 of 8) in pdf

General Assistance Application Page 3

JACKSON COUNTY GENERAL RELIEF

Application for Assistance

APPLICANT INFORMATION:

Name:__________________________________________________________________ Date: ____ / ____ /____

Last

First

Previous and Maiden Names

Address: _____________________________________________________________________________________

Street

City

State

Zip

County)

What date did you move to this address? ___________________________________________________________

Phone: (_____) -______-_______

Social Security Number ______-______-______

ASSISTANCE REQUESTED:

Shelter (Rent) ____

Food____

Burial____

Medical____

Personal Care Items____

Utilities including: Lights____

Water____

Fuel____

Other ____

HOUSEHOLD INFORMATION (STARTING WITH APPLICANT):

NAME

SEX

SS#

RELATIONSHIP

DOB

SELF

PERSONAL INFORMATION:

Are you your own guardian? Yes____ No____

I am presently: Single_____ Married_____ Divorced_____ Widowed_____ Separated_____ Other_____

Are you or your spouse a veteran? Yes____ No____ Enlist Date __________ Discharge Date __________

If service was during active war-time, and discharge was honorable,

here and contact worker.

How long have you lived in U.S?____________ Iowa?____________ Jackson County?____________

If less than one year, what other counties have you lived in?_____________________________________________

Have you ever received General Assistance from Jackson or another county?_______________________________

REASONS FOR DENIAL:

I understand that General Assistance shall be denied to a household who: does not meet the guidelines, refuses to answer any

questions on the application, fails to provide requested verification and/or information, attempts to falsify the application or

verifications, or misrepresents the household’s situation in any way.

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General Assistance Application Page 3

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